Page 12 - Benefit Guide_Heritage School 2020_Revised 9-25-2020

Dental Options:

Humana

2020 Rate Information
Dependent Information
Per Monthly Pay Period
Heritage School of Texas offers
Employee Only $ 42.11 employees the opportunity to cover
their spouse and dependent children.
Employee + Spouse $ 84.22 Children can join or remain on a
Employee + Child(ren) $113.63 parent’s dental plan until age 26.
When a child turns 26, they will lose
Employee + Family $156.99 dental coverage on the last day of their
birth month.

Humana Dental Traditional Plus 14
Type of Service
Non-Network Dentists - Reimbursed at 90th U&C

Calendar Year Deductible Individual $50 / Family $150

Preventive Services Covered at 100%; No Deductible

Basic Services Subject to $50 Deductible; Covered at 80%

Major Services Subject to $50 Deductible; Covered at 50%
Annual Maximum UNLIMITED

R&C Plan - pays 90% of the Usual and Customary charge for the area
Out of Network
where services are provided.
Orthodontia - Children under 19 Covered at 50% - Lifetime Maximum of $1,000 (No Deductible)
only

Type of Service Benefit Description

Routine Oral Examinations, Bitewing X-rays, 2 annual Routine cleanings,
Preventive Services Routine Cleanings, Fluoride Treatments Sealants to age 14. Oral Cancer
Screening (1 per year, ages 40 and older)
Services Include: Fillings, Simple Extractions, Endodontics (including Root
Basic Services Canal Treatment) Oral Surgery, 4 annual Periodontal Cleanings, Non-
surgical Periodontal Therapy-Scaling, Root Planning, Periodontal Surgery

Crowns, Inlays, Onlays and most related services, Bridges, Full and Partial
Dentures, Denture Reline and Rebase Services, Implant Related Services
Major Services (crowns, bridges, and dentures each limited to 1 per tooth every five
years. Implant coverage limited to equivalent cost of a non-implant
service. Implant placement itself is not covered.)

Orthodontia Applies only to children under age 19

Please note: This is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.

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